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Foundations Exam 2: Nursing Practice and Safety, Study Guides, Projects, Research of Nursing

University of Central Florida (UCF)Nursing

study guide exam 2 foundations

Typology: Study Guides, Projects, Research

2020/2021

Uploaded on 06/02/2023

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Foundations Exam 2
50 questions
6-8Q Restraints
6-8Q Safety
6-8Q Mobility
6-8Q Elimination
6-8Q Skin integrity and wound care
5Q Math (3 easy, 2 hard)
Math
• 20gtt = 1mL regular drip
• 60gtt = 1 mL micro drip
• 2.2 lb = 1kg
Patient weights 80kg
2mg/kg/day medication order…. How many? 160mg/day
153lbs 2mg/kg/day medication order…. How many? 139.1mg/day
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Foundations Exam 2 50 questions 6 - 8Q Restraints 6 - 8Q Safety 6 - 8Q Mobility 6 - 8Q Elimination 6 - 8Q Skin integrity and wound care 5Q Math (3 easy, 2 hard)

Math

  • 20gtt = 1mL regular drip
  • (^) 60gtt = 1 mL micro drip
  • 2.2 lb = 1kg Patient weights 80kg 2mg/kg/day medication order…. How many? 160mg/day 153lbs 2mg/kg/day medication order…. How many? 139.1mg/day

Safety

  • Factors Affecting Safety
    • Developmental
    • (^) Lifestyle
    • Mobility
    • Sensory Perception
    • (^) Knowledge
    • Communication
    • Physical Health
    • (^) Mental Health
  • The nursing Process for maintaining SAFETY
    • Assessment o (^) Mobility, Sensory perception, Awareness, Physical and Psychosocial health state
    • Diagnosis
    • (^) Outcome Identification and Planning
    • Implementation
    • Evaluation.
  • Special Risk Factor Assessment
    • Falls
    • Fires
    • Poisoning
    • Suffocation and chocking
    • (^) Firearm injuries
  • Client Outcomes for Safety
    • Identify o (^) Identify real and potential unsafe environmental situations.
    • Implement o (^) Implement safety measures in the environment.
    • (^) Use o (^) Use available resources for safety information
    • Incorporate o (^) Incorporate accident prevention practices into ADLs
    • Remain o (^) Remain free of injury
  • Factors that contribute to falls. What do we look for in an elderly patient?
    • Age > 65
    • Impaired vision or balance
    • (^) Impaired mobility, lower body weakness
    • History of falls
    • Altered gait, posture, or balance
    • Medication.
  • Chemical o (^) The use of any medication to subdue, sedate, or restrain a patient.
  • Physiological Hazard
  • Increased possibility of serious injury due to fall
  • (^) Skin breakdown
  • Contractures
  • Incontinence
  • (^) Depression
  • Delirium
  • Anxiety
  • (^) Aspiration and respiratory difficulties
  • Physician Orders
  • Must include type, duration, justification, and criteria for removal
  • Order must state reason and time period
  • An order will NEVER have PRN
  • In an emergency, they can be applied but an order from provider is required immediately
  • Alternative to restraints
  • (^) Place unstable patients in area constantly or closely supervised. A sitter
  • Establish ongoing assessment
  • 5 Criteria for selecting a restraint
  1. Restricts patients movement as little as possible
  2. Is safe for the specific client
  3. Does not interfere with patients treatment or health problem
  4. Is readily changeable
  5. Is discreet as possible

Mobility

  • What things can be caused in immobility?
    • (^) DVTs pressure sores, pneumonia, arthritis, hip fractures, Parkinson's disease.
    • Amputation
    • Neurological conditions
    • (^) Obesity
    • Terminal Illnesses
  • How to ambulate with assisted devices:
    • (^) Walker o (^) Have the patient stand up straight, the top of the walker should reach the crease of the wrist. o (^) The elbows should be slightly bent when they hold the handgrips of the walker o (^) Have them keep their back straight. Do not let them hunch over the walker.
    • Cane o (^) Have the patient stand straight, the top of the cane should reach the crease of the wrist. o (^) Their elbow should be slightly bent when holding the cane o (^) Have them hold the cane in the hand opposite the side that needs support.
    • Crutches o (^) Have the patient stand straight, the top of the crutches should be 1- 2 inches below their armpits o (^) The handgrip of the crutches should be even with the top of the patient hip line o (^) Elbows should be slightly bent when holding the handgrips o (^) The patient should rest on the hands, not on the underarm support to avoid damage to the nerve and blood vessels. o (^) When walking have patient lean forward slightly and put the crutches one foot in front of them.
    • (^) Braces o (^) Made to support weakened muscles and help keep them flexible. o (^) Can assist you to make the movements necessary for walking.

o (^) Fluid loss during illness cause by dehydration o (^) Skin appears loose and flabby

  • Excessive perspiration during illness
  • Jaundice causes itchy skin
  • (^) Diseases of the skin cause lesions that require care
  • Wounds and Pressure Injuries
  • Intentional or Unintentional
  • (^) Open or Closed
  • Acute or Chronic
  • Partial thickness, full thickness, complex (unstageable, deep tissue injury)
  • Wound healing
  • Proper nutrition, vitamin
  • (^) Clean/aseptic wound care.
  • Adequate blood supply
  • Phases of wound healing
  • Inflammatory: o (^) Begins at time of injury & prepares wound healing o (^) Hemostasis: blood clotting o (^) Inflammatory phase
  • Proliferation o (^) Granulation tissue forms creating scar tissue
  • (^) Maturation o (^) Final stage of healing
  • Factors Affecting wound healing
  • (^) Age
  • Circulation and oxygenation
  • Nutritional status
  • (^) Wound etiology
  • Health status
  • Immunosuppression
  • Medications
  • Adherence to treatment plan
  • Surgical Wound Complications
  • Infection
  • Hemorrhage
  • (^) Dehiscence o (^) Wound opening due to technical failure of sutures, shears forces from tension, fascial necrosis, infection and ischemia.
  • (^) Evisceration o (^) Uncontrolled exteriorization intraabdominal contents through the surgical wound outside of the abdominal cavity.
  • (^) Fistula formation

  • Pressure injury assessment:

    1. risk assessment
    2. Mobility
    3. Nutrition
    4. Moisture
    5. Appearance of existing pressure injury

  • Braden Scale

  • (^) Pain

  • Complication

  • Drainage

    1. Serous
    2. Sanguineous
    3. (^) Serosanguineous
    4. Purulent

  • Increase fiber in diet what else should you increase? H

  • Highest risk for developing skin breakdown

  • (^) Smoking, diabetes, anemia and other vascular conditions

  • Lowest risk for developing skin breakdown

  • Mental status, age, incontinence

  • When monitoring a patient with sign and symptoms of infection around wound… fever, erythema, warm to touch

  • (^) When touching skin what part of the hand… dorsal

  • Braden scale

  • Measures elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue tolerance for pressure. o (^) Sensory perception, moisture, activity, mobility, friction, and shear. o (^) The lower the number the higher the risk o (^) Severe Risk : < o (^) High Risk : 10 - 12 o (^) Moderate Risk: 13 - 24 o (^) Mild Risk : 15 - 18

Elimination

  • Incontinence
    • Functional Incontinence o (^) Caused by factors outside the urinary tract o (^) You cannot hold the urine - Patients with stroke, UTI, Pregnancy
    • Stress incontinence o (^) Increase in intra-abdominal pressure - (^) Increase in intra-abdominal pressure - When urine leaks out with sudden pressure on the bladder. o (^) To prevent practice Kegel exercise
  • Discharged frequency cannot be controlled because there is no sphincter to control it.
  • Nursing diagnoses with diarrhea and constipation
  • skin integrity
  • (^) dehydration
  • fluid and electrolyte
  • How to obtain sterile specimens
  • (^) Obtain specimen from the port of an indwelling catheter using sterile technique. Kahoot
  1. A client falls out of bed the nurse first completes
  2. An assessment
  • The nurse suspects a toddler has been abused. What is legally required of the nurse a. Report it to the authorities
  • A child is learning to ride a bicycle. Which would the nurse teach the child about bicycle safety?

a. Importance of wearing a helmet

  • What is a key concern when assisting a client ambulate following knee surgery a. Safety
  • A client is lactose intolerant. Which food is not permitted in the clients food tray? a. Custard
  • What is one topic that should be addressed to promote safety in a^ developing fetus? a. Smoking and alcohol consumption
  • What is the leading cause of injury related deaths in adults 65 and older? a. Falls
  • An older male client is admitted for dehydration… a priority education plan is made to ensure he a. Drink six to eight ounces per day (1500-2000 mLs)
  • A client with a new mid-thigh amputation refuses to look at the wound. Which response by the nurse is appropriate a. “I respect your wish not to look at it right now”
  • The nurse observes the client for signs of stage I pressure injury, which will include which finding? a. Non-^ blanchable redness
  • A client uses crutches following knee surgery. Client says “my armpits are so sore” what teaching is needed? a. “Try to bear your weight on your hands, not your armpits”
  • A client has abdominal cramps and bloody stools. Which assessment and diagnostic study should the nurse use? a. Bowel sounds and stool sample
  • The nurse is teaching the parents of a teenager about safety. Which teaching will the nurse include? a. Be alert for signs of peer pressure
  • The nurse completed a dressing change and returned the client to a comfortable position. What should the nurse do next? a. DOCUMENT DOCUMENT DOCUMENT (the odor, color, etc)
  • What guidelines will the nurse teach the client about using ice packs on a knee sprain at home? a. Use a cloth barrier around the ice pack
  • A nurse is promoting exercise activities for an older client. Which teaching point would be appropriate for this client? a. Encourage the client to warm up before the exercises